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Family physicians’ offices appear to be discriminating against the poor, a Toronto study concludes, after finding they are more willing to take on people of higher socioeconomic status as new patients.

Researchers from St. Michael’s Hospital posed as prospective patients looking for family physicians when they called 375 Toronto doctors’ offices in 2011. Following scripts, they explained either that they were bank employees who had recently transferred to Toronto, or welfare recipients.

The study, published online Monday in the Canadian Medical Association Journal, found the bank employees were 50 per cent more likely than the welfare recipients to get appointments.

“The most likely explanation is that people working in doctors’ offices may be unconsciously biased against people of low socioeconomic status,” said Dr. Stephen Hwang, a general internal medicine physician at the hospital and a researcher in its Centre for Research on Inner City Health.

It was mostly secretaries and administrative assistants who answered phone calls and provided information.

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“We don’t know for sure, but it’s (also) possible that physicians are telling their office staff the kind of patients they want to accept and office staff are simply carrying out the physicians’ directions,” Hwang said.

There was no financial incentive for doctors to see wealthier patients, since they get paid the same through Ontario’s publicly funded health insurance system, regardless of patients’ socioeconomic status.

The study also found that 9 per cent of doctors surveyed offered patients “screening visits,” otherwise known as “patient auditions.” Patients are invited for initial visits, during which doctors decide whether to continue seeing them.

“Ultimately, the screening visit poses a lot of additional opportunity to cherry-pick patients or to potentially discriminate,” Hwang said, adding that the college’s rules should be more strictly enforced.

In response to the study, the College said “it is not appropriate for physicians to screen potential patients because it can compromise public trust in the profession, and may also result in discriminatory actions against potential patients.

“Notwithstanding the first-come, first-served approach, physicians are permitted to prioritize treatment to those most in need,” said college spokesperson Kathryn Clarke.

On a positive note, the study found that an individual with chronic health issues was significantly more likely to get an appointment than someone without — 23.5 per cent compared with 12.8 per cent.

Prospective patient callers revealed they either had no health problems at all or that they suffered from diabetes and lower back pain.

The finding suggests patients with greater medical needs are being appropriately prioritized.

Hwang said this result was surprising and contrary to anecdotal evidence that doctors prefer to take healthier patients.

“We were expecting that healthy people would be favoured to get an appointment, because they are easier to take care of,” he said.

One limitation of the study was that researchers did not have access to information on how doctors were paid, a factor that could perhaps influence patient selection. Family physicians can be paid in three different ways: by fee-for-service, in which they bill OHIP for every service performed; by capitation, in which they get a set annual amount for each patient; or a combination of the two.

Fifteen per cent of Canadians report they do not have a regular doctor. Among those who have looked, the most common reason for not having a doctor is that local physicians are not accepting new patients.

Hwang was recently appointed to St. Mike’s new chair in homelessness, housing and health. He conducts a half-day clinic weekly at Seaton House in downtown Toronto, Canada’s largest shelter for men.

It was his experience in helping poor people in need of health care that inspired him to do this research.

“I’ve always been struck by the fact that many of my patients who are marginalized say that they have been treated poorly by health-care providers in the past, simply because of their position in society,” he said.

“When I’m taking care of patients, I’m also very aware of my own need to consciously guard against treating people who are affluent and influential differently from people who are poor and disadvantaged,” he added.

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